Electrodiagnostic severity does not predict short- to midterm outcomes of cubital tunnel release surgery.

HYPOTHESIS: This study aimed to explore the prognostic value of electrodiagnostic studies (EDS) to clarify their utility in clinical practice prior to cubital tunnel release surgery and to identify patient factors associated with patient-reported functional improvement after surgery. Our hypothesis was that patients with severe preoperative findings on EDS will tend to experience less functional improvement after surgery given the extent of ulnar nerve compressive injury. METHODS: Patients with cubital tunnel syndrome and preoperative electrodiagnostic data treated from 2012 to 2022 with cubital tunnel release were assessed regarding demographic information, preoperative physical examination findings, EDS findings, postoperative complications, and patient-reported outcomes. Short- to midterm quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) scores were collected for all patients for further evaluation of preoperative EDS data. Patients were grouped into those who had met the minimal clinically important difference (MCID) in delta qDASH at short- to midterm follow-up and those who did not. EDS data included sensory nerve onset latency, peak latency, amplitude, conduction velocity, as well as motor nerve latency, velocity, and amplitude. Electromyographic (EMG) studies were also reviewed, which included data pertaining to fibrillations, presence of abnormal fasciculation, positive sharp waves, variation in insertional activity, motor unit activity, duration of activity, and presence of increasing polymorphisms. RESULTS: Of the 257 patients included, 160 (62.0%) were found to meet the MCID for short- to midterm qDASH scores. There were no significant differences between patients who did or did not meet the MCID regarding baseline demographics, comorbidities, preoperative examination findings, and operative technique. Patients who met MCID tended to have lower complication (3.80% vs. 7.20%, P = .248) and revision (0.60% vs. 4.10%, P = .069) rates, but these findings were not statistically significant. The cubital tunnel severity as determined by the EDS was similar between cohorts (14.1% vs. 14.3%, P = .498). Analysis of EMG testing showed there were no significant differences in preoperative, short- to midterm qDASH, or delta short- to midterm qDASH scores for patients with or without abnormal EMG findings. Multivariate regression suggested that only age (P = .003) was associated with larger delta qDASH scores. CONCLUSION: Patient-reported preoperative disease severity may predict the expected postoperative change in ulnar nerve functional improvement, and EDS may not have prognostic value for patients undergoing cubital tunnel decompression. Therefore, physicians may suggest surgical treatment without positive EDS findings and still expect postoperative improvement in functional outcomes.

Risk Factors and Outcomes in Carpal Tunnel Syndrome Following Distal Radius Open Reduction Internal Fixation.

PURPOSE: Carpal tunnel syndrome (CTS) is a common complication following the operative repair of distal radius fractures. It is unclear who is at risk of developing this complication in the postoperative period. This study sought to identify risk factors for developing CTS and to evaluate patient-reported outcomes in patients who develop postoperative CTS. METHODS: A retrospective review of all distal radius fractures treated surgically at a single private academic center was performed from January 2007 to October 2019. Of the 4,487 patients, 68 were identified to have an ipsilateral carpal tunnel release within 6 months of the distal radius injury. Collected data comprised patient demographics, medical history, and functional outcome scores. RESULTS: Carpal tunnel syndrome was more likely to develop in older patients (62.9 years vs 57.4 years). Sex, body mass index, smoking history, and the type of insurance were not found to be significantly different between the groups. Medical history of kidney disease, psychiatric conditions, and peripheral vascular disease were found to be associated with developing CTS. Patients who developed CTS had higher average Disabilities of the Arm, Shoulder, and Hand scores than patients without CTS (28.1 vs 20.0) at the final follow-up. In a multivariable analysis, patients who developed CTS were found to be older (Odds ratio, 1.03) and less likely to be smokers (Odds ratio, 0.46). CONCLUSIONS: In our cohort, we observed that older patients were more likely to require carpal tunnel release following distal radius fracture. In addition, nonsmokers were more likely to require subsequent carpal tunnel release, probably as a result of confounding effects. Special care should be taken to monitor these patients for CTS in the postoperative period following a distal radius open reduction and internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Identifying High Direct Variable Costs of Open Carpal Tunnel Release Patients Using Time-Driven Activity-Based Costing.

PURPOSE: To improve value in health care delivery, a deeper understanding of the cost drivers in hand surgery is necessary. Time-driven activity-based costing (TDABC) more accurately reflects true resource use compared with traditional accounting methods. This study used TDABC to explore the facility cost of carpal tunnel release and identify preoperative characteristics of high-cost patients. METHODS: Using TDABC, we calculated the facility costs of 516 consecutive patients undergoing open carpal tunnel release at an orthopedic specialty hospital between 2015 and 2021. Patients in the top decile cost were defined as high-cost patients. Multivariable logistic regression was used to determine preoperative characteristics (age, sex, body mass index, race, ethnicity, Elixhauser comorbidity index, American Society of Anesthesiology score, preoperative Disabilities of the Arm, Shoulder and Hand score, Short-Form 12, and anesthesia type) independently associated with high-cost patients. RESULTS: Surgery-related personnel costs were the main driver (38.0%) of total facility costs, followed by preoperative personnel costs (21.3%). There was a 1.8-fold variation in facility cost between patients in the 90th and 10th percentiles ($774.69 vs $431.35), with the widest cost variations belonging to medication costs ($17.67 vs $1.85; variation, 9.6-fold) and other supply costs ($213.56 vs $65.56; variation, 3.3-fold). Using multivariable regression, predictors of high cost were patient age and use of general anesthesia. Total facility costs correlated strongly with the total operating room time and incision to closure time. CONCLUSIONS: Efforts to decrease operating room time may translate into reduced personnel costs and greater cost savings. Multidisciplinary initiatives to control medication expenses for patients at risk of high costs may narrow the existing variation in costs. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis II.

Appropriateness of Self-Scheduled Office Visits in Outpatient Hand Surgery.

PURPOSE: Our practice recently implemented a system that enables patients to self-schedule outpatient visits through an online portal. The purpose of this study was to evaluate the appropriateness of self-scheduled appointments in the Hand and Wrist Surgery Division of our practice. METHODS: Outpatient visit notes from 128 new patient visits among 18 fellowship-trained hand and upper extremity surgeons were collected; 64 visits were self-scheduled online, and 64 were scheduled using the traditional call center system. The notes were deidentified and divided among 10 hand and upper extremity surgeons, such that each note was reviewed by two different reviewers. The surgeons scored each visit on a scale of 1-10, with 1 representing a completely inappropriate visit for a hand surgeon and 10 representing a completely appropriate visit. Primary diagnoses and treatment plans were recorded, including whether surgery was planned during the visit. The final score for each visit resulted from the average of the two separate scores. The average appropriateness score for all self-scheduled visits was compared with the average score for all traditionally scheduled visits with a two-sample t test. RESULTS: The average appropriateness score for self-scheduled visits was 8.4 of 10, with seven visits resulting in a planned surgery (10.9%). Traditionally scheduled visits had an average appropriateness score of 8.4 of 10, with eight visits resulting in a planned surgery (12.5%). The average difference in the scores between reviewers for all visits was 1.7. CONCLUSIONS: In our practice, the appropriateness of visits that are self-scheduled is nearly identical to the appropriateness of traditionally scheduled visits. CLINICAL RELEVANCE: Implementation of self-scheduling systems may allow for greater patient autonomy and access to care and reduce administrative burden on office staff.

Patient Comprehension of Operative Instructions With a Paper Handout Versus a Video: A Prospective Randomized Control Trial.

PURPOSE: The purpose of this study was to evaluate the efficacy of a video versus that of a paper handout for explaining operative instructions for hand and upper extremity surgeries to patients. We aimed to compare patient performance using a knowledge-based questionnaire. In addition, we aimed to compare how helpful patients found their assigned operative instructions. METHODS: This was a randomized trial of 60 patients undergoing same-day hand and upper extremity surgeries. The patients were randomized to receive educational material outlining operative instructions, either in the form of a video link or a paper handout. At the first postoperative visit, the patients' comprehension of the content was evaluated using a questionnaire. The primary outcomes included the number of questions answered correctly and patient-reported evaluation of the provided instructions on a scale of 1-5. RESULTS: Patients who received video instructions scored higher in the questionnaire than those in the paper instructions group (paper: 58% correct; video: 76% correct). Moreover, patients in the video group were significantly more likely to answer questions pertaining to opioid use correctly. A higher proportion of patients in the video group than in the paper group found the information "extremely" or "very" helpful. CONCLUSIONS: This study found that the patients demonstrated greater comprehension of the operative instructions when these were administered in a video format than when these were administered as a printed handout. In particular, the results suggest that video-based education specifically improves patients' comprehension of proper opioid use. CLINICAL RELEVANCE: There appears to be utility in implementing videos for patient education purposes, particularly in the setting of operative instructions for same-day surgical procedures.

Wound Dehiscence Following Cubital Tunnel Surgery.

PURPOSE: Cubital tunnel syndrome is the second most common upper-extremity compressive neuropathy, and persistent symptoms can necessitate operative treatment. Surgical options include simple decompression and ulnar nerve transposition. The cause of wound dehiscence after surgery is not well known, and the factors leading to the development of these complications have not been previously described. METHODS: Patients undergoing ulnar nerve surgery from January 1, 2016, to December 31, 2019, were retrospectively evaluated for the development of wound dehiscence within 3 months of surgery. There were 295 patients identified who underwent transposition and 1,106 patients who underwent simple decompression. Patient demographics and past medical history were collected to evaluate the risk factors for the development of wound dehiscence. RESULTS: The overall rate of wound dehiscence following surgery was 2.5%. In the simple decompression group, the rate of wound dehiscence was 2.7% (30/1,106), which occurred a mean of 21 days (range, 2-57 days) following surgery. In the transposition group, the rate of wound dehiscence was 1.7% (5/295), which occurred a mean of 20 days (range, 12-32 days) following surgery. The difference in rates of dehiscence between the decompression and transposition groups was not significant. Five patients in the simple decompression group and 1 patient in the transposition group required a secondary surgery for closure of the wound. Age, body mass index, smoking status, and medical comorbidities were not found to contribute to the development of wound dehiscence. CONCLUSIONS: Wound dehiscence can occur following both simple decompression and transposition, even after postoperative evaluation demonstrates a healed wound. Surgeons should be aware of this possibility and specifically counsel patients about remaining cautious with, and protective of, their wound for several weeks after surgery. Dehiscence may be related to suboptimal vascularity in the soft tissue envelope in the posteromedial elbow. When it occurs, dehiscence can generally be treated by allowing healing by secondary intention. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Correlation of Carpal Tunnel Syndrome 6 Score and Physical Exam Maneuvers With Electrodiagnostic Test Severity in Carpal Tunnel Syndrome: A Blinded Prospective Cohort Study.

PURPOSE: Although carpal tunnel syndrome (CTS) can be diagnosed clinically with the Carpal Tunnel Syndrome 6 (CTS-6) evaluation tool, the relationship between disease severity and CTS-6 score has not been elucidated. The purpose of our study was to determine the correlation of the CTS-6 score and other physical examination maneuvers with the carpal tunnel severity grade by electrodiagnostic testing (EDT). We hypothesized that the CTS-6 score, Durkan test, and Semmes Weinstein Monofilament Testing (SWMT) positively correlate with EDT severity. METHODS: We prospectively enrolled 105 consecutive patients who presented to the office with suspected CTS, excluding those with previous surgery, previous EDT from an outside facility, or concomitant neuropathy. Four fellowship-trained hand surgeons obtained the CTS-6 score, time to obtain a positive Durkan compression test, and SWMT of the thumb, index, and middle fingers. All patients were sent for EDT. Hand surgeons were blinded to the results of the EDT, and the electrodiagnosticians were blinded to the clinical data. We used the Bland criteria (0-6) to grade CTS severity on EDT. This grade was compared with the CTS-6 score, Durkan time, and SWMT results. RESULTS: Using Spearman correlation coefficients, we found a weakly positive correlation between a higher CTS-6 score and a higher severity grade on EDT. The mean CTS-6 score based on EDT grading were the following: (1) 14.8 (grade 0), (2) 16.0 (grade 1), (3) 14.8 (grade 2), (4) 16.7 (grade 3), (5) 18.7 (grade 4), (6) 18.3 (grade 5), and (7) 22.4 (grade 6). We also found a statistically significant association between the SWMT and a higher CTS-6 score as well as a higher severity grade on EDT. Durkan compression test did not appear to correlate with the EDT grade. CONCLUSIONS: The CTS-6 and SWMT show a positive correlation with EDT severity in CTS on the basis of the Bland criteria. The time to a positive Durkan test did not show any correlation. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Effectiveness of Corticosteroid Injections in Diabetic Patients With De Quervain Tenosynovitis.

PURPOSE: We sought to determine the effectiveness of corticosteroid injections (CSIs) for de Quervain tenosynovitis in patients with diabetes mellitus. METHODS: We retrospectively identified all patients with diabetes receiving a CSI for de Quervain tenosynovitis by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, number and timing of CSIs, and first dorsal compartment release. Success was defined as not undergoing an additional CSI or surgical intervention. The mixture of a corticosteroid and local anesthetic provided in each injection was at the discretion of each individual surgeon. RESULTS: Corticosteroid injections were given to 169 wrists in 169 patients with diabetes. Out of 169 patients, 83 (49%) had success following the initial CSI, 44 (66%) following a second CSI, and 6 (67%) following a third CSI. A statistically significant difference was identified in the success rates between the first and second CSIs. Ultimately, 36 of 169 wrists (21%) underwent a first dorsal compartment release. CONCLUSIONS: Patients with diabetes mellitus have a decreased probability of success following a single CSI for de Quervain tenosynovitis in comparison to nondiabetic patients, as described in the literature. However, the effectiveness of each additional CSI does not appear to diminish. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

New Evaluation and Management Code Level Selection Trends in Hip and Knee Osteoarthritis Patients.

BACKGROUND: On January 1, 2021, the American Medical Association implemented changes regarding the outpatient Evaluation and Management (E/M) criteria dictating Current Procedural Terminology code level selection to help diminish administrative burden and emphasize medical decision-making as the primary determinant in E/M level of service (EML). The goal of this study was to describe EML coding trends in outpatient visits for hip and knee osteoarthritis after the 2021 Centers for Medicare and Medicaid Services changes to the E/M system. METHODS: All outpatient visits for primary hip and knee osteoarthritis within the divisions of Joint Replacement, Operative Sports Medicine, and Nonoperative Sports Medicine at a single orthopaedic practice were retrospectively analyzed during 2 separate 10-month timeframes in 2019 and 2021. The primary endpoint was the visit EML (1 through 5) based on Current Procedural Terminology E/M codes. RESULTS: In 2019, 7.8% of all visits were billed as level 2, 85.8% of all visits were billed as level 3, and 6.3% of all visits were billed as level 4. In 2021, 2.8% of visits were billed as level 2, 54% of visits were billed as level 3, and 41.3% of visits were billed as level 4. Level 1 and Level 5 visits did not exceed 2% in either year. Across all 3 divisions, level 2 and 3 visits decreased significantly (P < .05), while level 4 visits increased significantly (P < .05). CONCLUSION: Since the E/M coding criteria overhaul in 2021, there has been a significant trend towards higher level of service code selection across multiple divisions in our orthopaedic practice.

The Financial Implications of Telehealth Visits Within a Hand and Wrist Surgery Clinical Practice During the COVID-19 Pandemic.

PURPOSE: Telehealth use is likely to increase as a result of practice changes during the COVID-19 pandemic, although the overall picture surrounding the billing, coding, and continued insurance coverage of these visits remains uncertain. The purpose of this study was to identify potential financial implications of continued telehealth use in hand and wrist surgery clinical practice. METHODS: Two hundred telehealth visits were randomly selected and matched 1:1 based on primary diagnosis code to in-person visits. Medical and billing records were reviewed to compare visit complexities, total visit charges, work relative value units (wRVUs), and approved insurance reimbursement. Postoperative visits and visits with radiographic evaluation were excluded. RESULTS: Level 4 visits were more common with in-person encounters compared to telehealth (11% vs 2%, respectively), and level 1 and 2 visits were more common with telehealth compared to in-person encounters (14% vs 6%, respectively). Twenty-seven in-person visits (13%) had at least 1 additional procedure code billed. The mean total visit charge was 26% less in telehealth compared to in-person. Based on the primary procedure code alone, the sum of wRVUs was 15.1 points less in the telehealth cohort compared to in-person (per visit average, 1.1 [telehealth] vs 1.2 [in-person]). The 28 additional services provided during in-person visits accounted for an added 20.7 wRVUs. Unpaid claims were more common among telehealth encounters (8% [telehealth] vs 3% [in-person]). CONCLUSIONS: Higher complexity visits and visits with additional procedural codes billed were more common with in-person visits. This led to a lower number of total wRVUs and lower total visit charges among the included telehealth visits compared to the matched in-person controls. CLINICAL RELEVANCE: It is important to understand and consider the long-term financial impact of telehealth implementation. Practices must develop strategies to incorporate radiographic evaluation into telehealth visits and effectively stratify those patients that may require procedural interventions for in-person visits. Understanding the economic implications of this changing care delivery paradigm, providers can continue to provide telehealth services while protecting the financial sustainability of hand surgery practices.

Reliability of Radiographs and Computed Tomography in Diagnosing Scaphoid Union After Internal Fixation.

PURPOSE: To evaluate the reliability of radiographs (XR) alone versus the combination of XR and computed tomography (CT) in determining scaphoid union following open reduction internal fixation (ORIF) with a headless compression screw. METHODS: We used our imaging database to identify 32 XR and corresponding CTs over a 6-year period (from 2012 to 2018) that were performed to evaluate scaphoid healing following ORIF. Three hand surgeons evaluated the studies to assess (1) healing, (2) if partially healed, the percentage of healing, and (3) the certainty of healing. Initially, XR were reviewed alone. Three weeks later, the same XR were reviewed with the corresponding CTs. Each reviewer performed a similar 2-stage evaluation 4 weeks later. We measured interobserver and intraobserver reliabilities using linearly weighted kappa (κ) coefficients for healing status and the percentage of healing. RESULTS: The interobserver reliability for healing (healed vs partially healed vs not healed) was moderate both with XR alone and with the combination of XR and CT. The intraobserver reliability for healing was substantial with XR alone compared to moderate with the combination of XR and CT. For the percentage of healing, both interobserver and intraobserver reliabilities were fair with XR alone or with the combination of XR and CT. Reviewers reported significantly greater certainty with the combination of XR and CT compared with XR alone. CONCLUSIONS: Following ORIF, surgeons are more certain in their evaluation of scaphoid healing with the combination of CT and XR. However, the reliability of assessing scaphoid union may not be improved by the addition of CT to XR. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

On Emerging Technology: What to Know When Your Patient Has a Microchip in His Hand.

Radio-frequency identification (RFID) technology uses an antenna to respond to an incoming signal by sending an outgoing message. This technology has been in use for over 50 years and is common in daily activities such as tapping a credit card to a reader, swiping an ID badge to open a door, paying highway tolls, and operating keyless entry cars. This technology can be implanted, such as in the microchips used to identify domestic pets. Since 1998, RFID chips have also been implanted in humans. This practice is little studied but appears to be increasing; rice-sized implants are implanted by hobbyists and even offered by some employers for uses ranging from access to emergency medical records to entry to secured workstations. These implants are of special concern to hand surgeons because they are most commonly placed in the subcutaneous dorsal first web space. The US Food and Drug Administration first approved this technology in 2004, with stated potential risks including adverse tissue reaction, migration of the implanted transponder, compromise of information security, electrical hazards, and magnetic resonance imaging incompatibility. Here, we explain implanted RFID technology, its potential uses, and what is and is not known about its safety. We present images of a patient with an RFID chip who presented to our clinic for acute metacarpal and phalangeal fractures, to demonstrate the clinical and radiographic appearance of these chips.

Risk of Infection in Trigger Finger Release Surgery Following Corticosteroid Injection.

PURPOSE: To determine the risk for infection in trigger finger release surgery after preoperative corticosteroid injection. METHODS: We retrospectively evaluated all patients undergoing trigger finger release by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, trigger finger(s) operated on, presence of a prior corticosteroid injection, date of most recent corticosteroid injection, postoperative signs of infection, and need for surgery owing to deep infection. Superficial infection was defined per Centers for Disease Control criteria. Deep infection was defined as the need for surgery related to a surgical site infection. RESULTS: In this cohort of 2,480 fingers in 1,857 patients undergoing trigger release surgery, 53 (2.1%) developed an infection (41 superficial [1.7%] and 12 deep [0.5%]). Before surgery, 1,137 fingers had no corticosteroid injection. These patients developed 1 deep (0.1%) and 17 superficial (1.5%) infections. In contrast, 1,343 fingers had been given a corticosteroid injection before surgery. These patients developed 11 deep (0.8%) and 24 superficial (1.8%) infections. Median time from corticosteroid injection to trigger release surgery was shorter for fingers that developed a deep infection (63 days) compared with those that developed no infection (183 days). The risk for developing a deep infection in patients who were operated on within 90 days of an injection (8 infections in 395 fingers) was increased compared with patients who were operated on greater than 90 days after an injection (3 infections in 948 fingers). CONCLUSIONS: Preoperative corticosteroid injections are associated with a small but statistically significantly increased rate of deep infection after trigger finger release surgery. The risk for postoperative deep infection seems to be time dependent and greater when injections are performed within 90 days of surgery, especially in the 31- to 90-day postinjection period. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Optimal Position for Arthrodesis of the Proximal Interphalangeal Joints of the Border Digits.

PURPOSE: This study aimed to determine the functional characteristics of various arthrodesis angles of the proximal interphalangeal (PIP) joints of the border fingers. METHODS: The dominant hands of 48 volunteers were tested using custom orthoses to simulate PIP joint arthrodesis. For the index finger (IF), orthoses were made in 25°, 40°, and 55° of flexion (IF25, IF40, and IF55). For the little finger (LF), orthoses were made in 30°, 55°, and 70° of flexion (LF30, LF55, and LF70). Twenty-three volunteers performed grip and pinch (key, tripod, and pulp) strength testing with and without simulated arthrodeses and 25 volunteers performed the Jebsen Hand Function Test (JHFT) with and without simulated arthrodeses. Simulated conditions of arthrodesis were compared with the unrestricted state and with each other within the same finger. RESULTS: For grip and pinch strength, there were no significant differences between simulated arthrodesis angles. Compared with baseline, grip was significantly weaker for all 6 simulated arthrodesis angles. Pinch was tested with simulated IF arthrodesis only; key pinch was significantly weaker for all tested angles and tripod pinch for IF25 and IF40. For JHFT, the 3 experimental angles for the index or ring finger did not show any statistically significant differences for any subtest. Volunteers were slower at completion times for all simulated arthrodesis angles compared to baseline times. This was significant in 5 of 7 tasks for IF25, 3 of 7 tasks for IF40, and 4 of 7 tasks for IF55. Index finger angle of flexion of 40° was significantly faster than IF55 for writing and IF25 for lifting large, light objects. For the LF, LF30 was significantly slower than baseline for 6 of 7 tasks, LF55 for 3 of 7 tasks, and LF70 for 5 of 7 tasks. Index finger angle of flexion of 55° was significantly faster than LF70 for simulated feeding and IF30 for lifting large, heavy objects. CONCLUSIONS: No border digit PIP joint arthrodesis angle was superior for grip and pinch strength. Based on JHFT, IF40 and LF55 might be preferred arthrodesis angles. CLINICAL RELEVANCE: Intermediate arthrodesis angles may provide the best function for patients undergoing PIP joint arthrodesis of the IF and LF.

Biologic and mechanical aspects of tendon fibrosis after injury and repair.

Tendon injuries of the hand that require surgical repair often heal with excess scarring and adhesions to adjacent tissues. This can compromise the natural gliding mechanics of the flexor tendons in particular, which operate within a fibro-osseous tunnel system similar to a set of pulleys. Even combining the finest suture repair techniques with optimal hand therapy protocols cannot ensure predictable restoration of hand function in these cases. To date, the majority of research regarding tendon injuries has revolved around the mechanical aspects of the surgical repair (i.e. suture techniques) and postoperative rehabilitation. The central principles of treatment gleaned from this literature include using a combination of core and epitendinous sutures during repair and initiating motion early on in hand therapy to improve tensile strength and limit adhesion formation. However, it is likely that the best clinical solution will utilize optimal biological modulation of the healing response in addition to these core strategies and, recently, the research in this area has expanded considerably. While there are no proven additive biological agents that can be used in clinical practice currently, in this review, we analyze the recent literature surrounding cytokine modulation, gene and cell-based therapies, and tissue engineering, which may ultimately lead to improved clinical outcomes following tendon injury in the future.

Peripheral nerve injury, scarring, and recovery.

Peripheral nerve injuries (PNI) resulting from trauma can be severe and permanently debilitating. Despite the armamentarium of meticulous microsurgical repair techniques that includes direct repair, grafting of defects with autograft nerve, and grafting with cadaveric allografts, approximately one-third of all PNI demonstrate incomplete recovery with poor restoration of function. This may include total loss or incomplete recovery of motor and/or sensory function, chronic pain, muscle atrophy, and profound weakness, which can result in lifelong morbidity. Much of this impaired nerve healing can be attributed to perineural scarring and fibrosis at the site of injury and repair. To date, this challenging clinical problem has not been adequately addressed. In this review, we summarize the existing literature surrounding biological aspects of perineural fibrosis following PNI, detail current strategies to limit nerve scarring, present our own work developing reliable nerve injury models in animal studies, and discuss potential future studies which may ultimately lead to new therapeutic strategies.

Surgical Loupes Worn by Orthopaedic Surgeons Are a Reservoir for Microorganisms.

BACKGROUND: Surgeons frequently use optical loupes to magnify the surgical field; they are typically unprotected when positioned directly over the wound, where particulate shedding containing microorganisms could potentially lead to surgical site infections (SSIs). SSIs are rare in some orthopaedic subspecialties such as hand surgery; however, in other subspecialties, for example, the spine, where surgeons often use loupes, SSIs can have devastating consequences. QUESTIONS/PURPOSES: (1) What is the degree of bacterial and fungi organism colonization of surgical loupes and storage cases? (2) Is there a difference in the degree of colonization at the beginning and the end of a surgery day? (3) Does an alcohol swab reduce bacterial colonization of surgical loupes? METHODS: The surgical loupes of 21 orthopaedic surgeons from a large, regional orthopaedic practice were cultured over a 3-month period and form the basis of this study. Five loupe storage cases were also cultured. In two different subgroup comparisons, the presence of microorganisms was evaluated just before the start and immediately after the end of the surgical day (n = 9) and before and 1 minute after cleaning with an alcohol swab (n = 6). A total of 36 cultures were evaluated. Surgeons who declined to participate in the study were excluded. The number of loupes selected for all of the analyses were samples of convenience and limited by surgeon availability. The degree of bacterial and fungal presence was graded using a point system: 0 = no growth; 1 = limited growth (meaning few scattered colonies); 2 = moderate growth; 3 = extensive but scattered growth; and 4 = growth consuming the entire plate. Demographic data were assessed using descriptive statistics. Additionally, the Student's t and Wilcoxon signed-rank tests were used to detect differences in categorical bacterial growth between paired samples. A p value of 0.05 represented statistical significance. Kappa statistics of reliability were performed to evaluate interobserver agreement of microorganism growth in the culture plates. RESULTS: Bacteria were present in 19 of 21 (90%) sets of loupes. Five species of bacteria were noted. Fungi were present in 10 of 21 (48%) sets of loupes. Bacterial contamination was identified in two storage cases (40%) and fungi were present in five cases (100%). In a subset of nine loupes tested, the degree of bacterial presence had a median of 2 (range, 1-4; 95% confidence interval [CI], 1.0-2.6) in samples collected before starting the surgical day compared with 3 (range, 2-4; 95% CI, 2.0-3.3) at the end of the day (p = 0.004). In a separate study arm comprised of six loupes, 1 minute after being cleaned with an alcohol swab, bacterial presence on loupes decreased from a median of 2 (range, 2-3; 95% CI, 1.9-2.5) to a median of 1 (range, 0-2; 95% CI, 0.5-1.5; p = 0.012). CONCLUSIONS: Loupes are a common reservoir for bacteria and fungi. Given the use of loupes directly over the surgical field and the lack of a barrier, care should be taken to decrease the bacterial load by cleaning loupes and airing out storage cases, which may decrease the risk of surgical field contamination and iatrogenic wound infections. CLINICAL RELEVANCE: Routine cleaning and disinfecting of optical loupes with alcohol pads can reduce microorganism colonization and should be implemented by surgeons who regularly use loupes in the operating room. Theoretically, particulate shedding from the loupes into the surgical field containing microorganisms could increase the risk of SSI, although this has not been proven clinically.

Preoperative Exposure to Benzodiazepines or Sedative/hypnotics Increases the Risk of Greater Filled Opioid Prescriptions After Surgery.

BACKGROUND: The effect of the preoperative exposure to controlled substances such as benzodiazepines and sedative/hypnotics on prolonged opioid consumption after hand surgery is not known. QUESTIONS/PURPOSES: (1) Is preoperative exposure to benzodiazepines and sedative/hypnotics associated with greater numbers of filled postoperative opioid prescriptions after hand surgery? (2) Is a positive history of the use of more than one controlled substance, a mood disorder, or smoking associated with greater numbers of filled opioid prescriptions after surgery? (3) Is preoperative exposure to opioids associated with greater numbers of filled postoperative opioid prescriptions after hand surgery? METHODS: Patients undergoing upper extremity surgery at one academic outpatient surgical center were prospectively enrolled. The Pennsylvania Drug Monitoring Program (PDMP) website was used to document prescriptions of opioids, benzodiazepines, and sedative/hypnotics filled 6 months before and after the procedure. Patients were grouped into exposed or naïve cohorts depending on whether a prescription was filled 6 months before surgery. Smoking history (current or previous smoking was considered positive) and a history of mood and pain disorders (as noted in the medical history), were collected from the outpatient and the operating room electronic medical record. RESULTS: After controlling for age, gender, and other confounding variables, we found that a history of exposure to benzodiazepines is associated with a greater number of filled postoperative opioid prescriptions (not-exposed, 1.2 ± 1.3; exposed, 2.2 ± 2.5; mean difference, 1.0; 95% confidence interval [CI], 0.5-1.5; p < 0.001); likewise, exposure to sedative/hypnotics is associated with greater opioid prescription fills (not-exposed, 1.2 ± 1.4; exposed, 2.3 ± 2.9; mean difference, 1.1; 95% CI, 0.3-1.9; p = 0.006). Patients who had used more than one controlled substance had more filled opioid prescriptions when compared with those not using more than one controlled substance (3.9 ± 3.5 versus 2.1 ± 1.2; mean difference, 1.8; 95% CI, 0.8-2.8; p = 0.002); patients with mood disorders also had more filled prescriptions when compared with those without mood disorders (2.0 ± 2.5 versus 0.9 ± .8; mean difference, 1.1; 95% CI, 0.7-1.5; p < 0.001); and finally, smoking history is associated with more filled prescriptions (1.9 ± 2.3 versus 1.2 ± 1.5, mean difference, 0.8; 95% CI, 0-1.4; p = 0.040). CONCLUSIONS: Patients exposed to benzodiazepines and sedative/hypnotics have prolonged use of opioids after surgery. Undergoing outpatient upper extremity surgery and being prescribed an opioid did not change the patterns of controlled substance use. Based on the results of this study, we are now more aware of the potential problems of patients with exposure to controlled substances, and are more attentive about reviewing their history of substance use in the PDMP website, an important resource. In addition, we now provide much more detailed preoperative counseling regarding the use and abuse of opioid medication in patients with exposure to benzodiazepines, sedatives, and those with a smoking history and mood disorders.Level of Evidence Level II, therapeutic study.

The Effect of Intraoperative Corticosteroid Injections on the Risk of Surgical Site Infections for Hand Procedures.

PURPOSE: The aim of the study was to assess the risk of surgical site infection (SSI) in patients who received an intraoperative injection (IOI) with a corticosteroid at the same time as hand surgery for a different condition. METHODS: This was a retrospective chart review of all patients who underwent hand surgery and corticosteroid injections concurrently over an 8-year period. Comparison of the rates of SSI was made of patients who had received an IOI and a matched control cohort of patients with no intraoperative injection (nIOI). There were 391 patients in each group. RESULTS: There were 8 SSIs in the IOI group compared with 2 in the nIOI group. One patient in the IOI group had a deep infection whereas all other infections were superficial. In the IOI group, 206 patients had injections on the side ipsilateral to their surgical procedure. Six of these patients had SSIs, a significant difference compared with the control group. There were 185 patients who had contralateral injections. Two of these patients had SSIs. Compared with the control group, this difference was not significant. CONCLUSIONS: Concomitant injection of steroid into the same side as the surgical site increases the risk of postoperative infection. We do not recommend administering a corticosteroid injection at the time of hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Delayed, Atraumatic Index Metacarpal Fracture After Trapeziectomy and Suture-Button Suspensionplasty for Thumb Carpometacarpal Osteoarthritis: A Report of Three Cases.

Trapeziectomy with suture-button suspensionplasty is a surgical treatment option for thumb carpometacarpal osteoarthritis refractory to nonsurgical management. We describe the cases of 3 patients who presented with index metacarpal fracture, in the absence of traumatic injury, over 4 months after trapeziectomy with suture-button suspensionplasty. All 3 fractures demonstrated the same pattern: short oblique/spiral, oriented proximal radial to distal ulnar with the distal end in the vicinity of the index metacarpal button, presumably after the orientation of the metacarpal drill hole. Two of the fractures were treated with surgical fixation. Fracture healing was obtained in all cases. Two of the 3 patients remained symptomatic with thumb pain, but decided against revision treatment for the carpometacarpal osteoarthritis. The third underwent restabilization of the suture button at the time of fracture fixation. Although uncommon, index metacarpal fracture after trapeziectomy with suture-button suspensionplasty can present without trauma several months after surgery.